Academic achievement in children with oral clefts versus unaffected siblings

Screening for Academic Risk Among Students With Cleft Lip and/or Palate: Patterns of Risk and Qualities of Effective Tools

This study evaluated the effectiveness of academic screening measures in relation to parent-reported diagnoses.

Multicenter, retrospective cohort study including structured interviews, questionnaires, and chart reviews.

Six North American cleft centers.

Children (n = 391) with cleft lip and/or palate, ages 8 to 10 years of age (192 male) and their guardians were recruited during regular clinic visits.

Parent and child ratings on the Pediatric Quality of Life Inventory (PedsQL) School Scale, child report on CleftQ School Scale, parent report on the Adaptive Behavior Assessment System-Third Edition Functional Academics (ABAS-FA) Scale and Child Behavior Checklist (CBCL) School Competency Scale, parent interview, and medical chart review.

Risk for concerns ranged from 12% to 41%, with higher risk reflected on the CBCL-SC compared to other measures. Males with cleft palate were consistently at the highest risk. Only 9% of the sample had a parent-reported diagnosis of a learning or language disability. Ratings from the ABAS-FA and CBCL-SC had the highest utility in identifying those with language and/or learning concerns.

As cleft teams work to develop standardized batteries for screening and monitoring of patients, it is important to evaluate the effectiveness of measures in identifying those at highest risk. When screening for language and learning disorders, questions related to potential academic struggles, such as increased school effort or increased school distress, are most useful. Referrals for follow-up evaluation are recommended for those identified at high risk.

Association Between Gestational Age and Academic Achievement of Children Born at Term

Importance

Differences in academic achievement by gestational age of children born at term, especially at 39 to 41 weeks, are not well understood.

Objective

To examine differences in academic achievement among children born between 37 and 41 weeks' gestational age.

Design, Setting, and Participants

This retrospective cohort study linked birth certificates of children born in Iowa from 1989 to 2009 with school test scores for grades 2 to 11 from 2017 to 2018. Statistical analysis was performed from January to March 2023.

Exposures

Gestational age at 37, 38, 39, and 41 weeks vs 40 weeks from clinical or obstetric and calendar measures.

Main Outcomes and Measures

Outcomes were scores in national percentile rankings (NPRs) on standardized school tests in math and reading. Covariates included demographic and prenatal risk factors.

Results

The sample included 536 996 children (50.7% male children and 49.3% female children) with math scores (3 576 045 child-grade observations; 6.6%, 15.7%, 28.6%, 35.5%, and 13.7% born at 37, 38, 39, 40, and 41 weeks, respectively) and 537 078 children with reading scores (3 590 408 child-grade observations). Score differences for those born at 39 vs 40 weeks were -0.028 NPRs (95% CI, -0.18 to 0.12 NPRs) for math and 0.085 NPRs (95% CI, -0.067 to 0.24 NPRs) for reading using the clinical or obstetric measure and 0.03 NPRs (95% CI, -0.14 to 0.20 NPRs) for math and 0.13 NPRs (95% CI, -0.042 to 0.31 NPRs) for reading using the calendar measure. With the clinical or obstetric measure, score differences between those born at 41 and 40 weeks were 0.19 NPRs (95% CI, -0.0052 to 0.38 NPRs) for math and 0.098 NPRs (95% CI, -0.096 to 0.29 NPRs) for reading. With the calendar measure, score differences for those born at 41 weeks were -0.22 NPRs (95% CI, -0.43 to -0.013 NPRs) for math and -0.28 NPRs (95% CI, -0.49 to -0.074 NPRs) for reading. With the clinical or obstetric measure, score differences between those born at 37 and 38 weeks vs 40 weeks were -0.59 NPRs (95% CI, -0.84 to -0.33 NPRs) and -0.44 NPRs (95% CI, -0.62 to -0.26 NPRs), respectively, for math, and -0.066 NPRs (95% CI, -0.32 to 0.19 NPRs) and -0.19 NPRs (95% CI, -0.37 to 0.0038 NPRs), respectively, for reading.

Conclusions and Relevance

This study suggests that there is no evidence of a difference in math and reading scores over grades 2 to 11 among children born between 39 and 40 weeks' gestation, and overall no evidence of better scores among those born at 41 weeks' gestation compared with 40 weeks' gestation. The results can further inform decisions on delivery timing at term birth by offering insights into long-term associations of delivery timing with cognitive development and school achievement.

A preliminary examination of expressive writing in boys with isolated orofacial clefts

BACKGROUND

Children with isolated cleft of the lip and/or palate (iCL/P) are at a higher risk for language and reading issues. The current pilot study evaluated concurrent writing skills of children with iCL/P compared to unaffected participants with average (uAR) and impaired (uIR) reading. It was hypothesized that children with iCL/P would perform lower than age-expectations.

METHODS

Twenty-three males, aged 8-11 years old, were recruited through clinics, local advertisements, and state dyslexia groups (iCL/P = 7, uAR = 8, uIR = 8). Group differences on measures of cognitive processes and writing were evaluated using ANCOVA. Relationships between these measures were compared for each group through Pearson correlations.

RESULTS

Participants with iCL/P performed within the average range across all measures; group differences were only found for the uIR group. For those with iCL/P, writing was correlated to global cognitive skills rather than more specific skills.

CONCLUSIONS

While this small sample of children with iCL/P demonstrated average writing skills, patterns suggest performance is related to global cognitive reasoning rather than specific cognitive processes as found in unaffected children with impaired reading. Further research is needed to better understand writing in iCL/P and the relationship to reading and cognitive processes.

IMPACT

Research in children with isolated cleft of the lip and/or palate (iCL/P) has demonstrated higher rates of language and reading disorders. No work has assessed written expression in children with iCL/P in over 40 years. This study is the first to evaluate elements of written expression and associated cognitive processes among children with iCL/P in comparison to unaffected children with either average or impaired reading skills. Measures of writing were within the average range for children with iCL/P and demonstrated correlation to global cognitive reasoning rather than to specific cognitive processes as found in unaffected children with impaired reading.

Isolated oral clefts and school grades: population-based cohort study from Norway

OBJECTIVE

To compare school grades of adolescents in Norway born with isolated cleft with those of their unaffected peers.

DESIGN

Population-based cohort study.

SETTING

Norway.

PATIENTS

A total of 347 419 individuals born in Norway between 1986 and 1992, including 523 isolated cleft cases which were identified using data from Norway's two treatment centres. Individuals were followed from birth through compulsory school.

MAIN OUTCOME MEASURES

Grade point average (GPA) from middle school graduation (around the age of 16). Specific subject grades were also investigated.

RESULTS

Using a grade scale from 1-6, the observed mean GPA for the reference group was 3.99. Both cleft lip only (CLO) and cleft lip with cleft palate (CLP) had a mean GPA similar to the reference group (adjusted GPA differences from the reference with 95% CIs of 0.06 (-0.04 to 0.16) and -0.08 (-0.19 to 0.03), respectively). Cleft palate only (CPO) had a marginally lower GPA (adjusted GPA difference: -0.18 (-0.28 to -0.08)). These comparisons were consistent across specific subjects. Overall, the evidence suggests a larger difference in GPA between cases and controls in males compared with females. Females with CLO even had a higher estimated GPA than females in the reference group (adjusted GPA difference: 0.19 (0.013 to 0.36)). Grades were similar regardless of laterality of cleft lip (CLO or CLP).

CONCLUSION

In Norway, individuals born with isolated CLO or CLP did not have lower average school grades when graduating from middle school. Individuals born with isolated CPO had marginally lower grades.

Reading Development in Children With Nonsyndromic Cleft Palate With or Without Cleft Lip: Meta-analysis and Systematic Review

OBJECTIVE

We conducted a meta-analysis and systematic review of literature comparing pre-reading and general reading in school-age children with nonsyndromic cleft palate with or without cleft lip (NSCP/L) to their peers without NSCP/L.

METHODS

Our literature search identified 1238 possible records. After screening we identified 11 samples for inclusion for systematic review and eight for meta-analysis. We compared 292 children with NSCP/L to 311 peers for 23 pre-reading effect sizes and 17 general reading effect sizes (EF_g). We conducted a random-effects metaregression using robust variance estimation.

RESULTS

On average school-age children with NSCP/L scored lower on pre-reading (EF_g = -0.36) and general reading measures (EF_g = -0.38) compared to their peers. We conducted post-hoc analyses on phonological awareness and word decoding effect sizes; children with NSCP/L performed lower on phonological awareness (EF_g = -0.22) and word decoding (EF_g = -0.39) compared to their peers. There was weak evidence that hearing status and/or speech-language functioning might moderate reading development. There was limited evidence that age or socioeconomic status moderated reading development. However, samples did not consistently report several characteristics that were coded for this project.

CONCLUSIONS

Our findings suggest that school-age children with NSCP/L have persistent reading problems. Further research is needed to explore reading development in children with NSCP/L, as well as the relationships among hearing, speech, language, and reading development.

Brain Developmental Trajectories in Children and Young Adults with Isolated Cleft Lip and/or Cleft Palate

The present study evaluated brain development in persons with isolated cleft lip and/or cleft palate (iCL/P) compared to unaffected controls using an accelerated longitudinal design. A sample of 134 males and females, ages 7-27 years, with iCL/P (184 observations, total) was compared to 144 unaffected controls (208 evaluations, total) on Wechsler Index scores and volumetric data from structural MRI scans. Boys with isolated cleft palate had verbal IQ 15.5 points lower than perceptual IQ; a clinically significant difference. Participants with iCL/P had differential growth trajectories of regional cerebrum matter and consistently lower volumes of cerebellar gray matter and subcortical matter.

Cleft lip/palate and educational attainment: cause, consequence or correlation? A Mendelian randomization study

BACKGROUND

Previous studies have found that children born with a non-syndromic orofacial cleft have lower-than-average educational attainment. Differences could be due to a genetic predisposition to low intelligence and academic performance, factors arising due to the cleft phenotype (such as social stigmatization, impaired speech/language development) or confounding by the prenatal environment. A clearer understanding of this mechanism will inform interventions to improve educational attainment in individuals born with a cleft, which could substantially improve their quality of life. We assessed evidence for the hypothesis that common variant genetic liability to non-syndromic cleft lip with or without cleft palate (nsCL/P) influences educational attainment.

METHODS

We performed a genome-wide association study (GWAS) meta-analysis of nsCL/P with 1692 nsCL/P cases and 4259 parental and unrelated controls. Using GWAS summary statistics, we performed Linkage Disequilibrium (LD)-score regression to estimate the genetic correlation between nsCL/P, educational attainment (GWAS n = 766 345) and intelligence (GWAS n = 257 828). We used two-sample Mendelian randomization to evaluate the causal effects of genetic liability to nsCL/P on educational attainment and intelligence.

RESULTS

There was limited evidence for shared genetic aetiology or causal relationships between nsCL/P and educational attainment [genetic correlation (rg) -0.05, 95% confidence interval (CI) -0.12 to 0.01, P 0.13; MR estimate (βMR) -0.002, 95% CI -0.009 to 0.006, P 0.679) or intelligence (rg -0.04, 95% CI -0.13 to 0.04, P 0.34; βMR -0.009, 95% CI -0.02 to 0.002, P 0.11).

CONCLUSIONS

Common variants are unlikely to predispose individuals born with nsCL/P to low educational attainment or intelligence. This is an important first step towards understanding the aetiology of low educational attainment in this group.

Perceptions Regarding the Academic and Cognitive Performance of Individuals With Cleft Lip and/or Palate

INTRODUCTION

Factors such as teachers' appropriate support and social interactions have an impact on the academic performance of children with cleft lip and/or palate (CL/P). This study was designed to investigate the perceptions of the teachers and the general public about the academic and cognitive performance of individuals with CL/P.

METHODS

This study was included 360 (male/female = 102/258) teachers and 640 (male/female = 259/381) participants that represent the general public. Anonymized web-based and paper-and-pencil self-administered questionnaire that included multiple-choice and yes/no questions were administered. Within-group differences and intergroup differences were analyzed in terms of academic and cognitive performance.

RESULTS

Most of the teachers and the general public indicated that the academic and cognitive performance of individuals with CL/P is the same as their unaffected peers. A significantly higher proportion of the teachers indicated that the academic performance of children with CL/P is the same as their unaffected peers than the general public.

CONCLUSION

Considering that the general public's attitudes and appropriate teacher support are crucial to prevent adverse impacts on the lives of individuals with CL/P, it is important to support teachers with the appropriate information and to encourage the public to recognize that everybody with a facial difference should be treated as an individual rather than a disability.

Retrospective Evaluation of Number of Surgeries and Parent Ratings of Academic and Behavioral Functioning Among Children With Isolated Oral Clefts

OBJECTIVE

The purpose of this study was to evaluate possible relationships between number of surgeries and parent ratings of academic functioning among children with isolated oral clefts.

DESIGN

Multicenter, retrospective cohort study including structured interviews, questionnaires, and chart reviews.

SETTING

Completion of questionnaires occurred during clinical visits at 6 different cleft centers across North America.

PARTICIPANTS

Parents of 285 children with isolated clefts of the lip and/or palate, aged 8 to 10 years old, participated in structured interviews and completed questionnaires regarding the academic and behavioral functioning of their children.

MAIN OUTCOME MEASURES

Parent interview and medical chart review of number of surgeries to date and parent ratings on the Adaptive Behavior Assessment System, Third Edition-Functional Academics Scale (ABAS-FA) and Child Behavior Checklist (CBCL) Total Competency Scale.

RESULTS

Parent ratings of ABAS-FA were at or above normative expectations, while ratings across CBCL Competency Scales were lower than normative expectations. Socioeconomic status (SES), age, and race were consistent predictors of parent ratings (higher SES, older age, and Caucasian race were associated with better functioning). Number of surgeries did not add significantly to academic ratings but did significantly contribute to ratings of social and activity participation. Patients with more surgeries were rated with lower functioning in these domains.

CONCLUSIONS

Findings do not support a connection between number of surgeries and later ratings of academic functioning but do support a connection to social and activity involvement. Recommendations for conducting direct studies of the connection between surgeries and academic functioning as well as clinical considerations for surgeries and impact on social and activity involvement are discussed.

Cleft lip and palate: Care configuration, national registration, and research strategies

A child born with a cleft lip and palate will face 20 years or more of hospital care and surgery. This is a global problem with approximately 10 million people affected worldwide. Various models of care exist around the condition, and the best configurations of services within an economy need to be optimized. We provide examples of how centralized care can improve outcomes and provide an opportunity to establish national registries, and then emphasize the opportunities for building research platforms of relevance. The default of any cleft service should be to centralize care and enable cleft teams with a sufficient volume of patients to develop proficiency and measure the quality of outcomes. The latter needs to be benchmarked against the better centers in Europe. Two areas of concern for those with cleft are morbidity/mortality and educational attainment. These two issues are placed in context within the literature and wider approaches using population genetics. Orthodontists have always played a key role in developing these initiatives and are core members of cleft teams with major responsibilities for these children and their families.

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Cleft lip and palate affects about 10 million people worldwide.

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Centralised care can improve outcome and establish national registries.

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Orthodontists have played a key role in developing these initiatives.

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No strong evidence of an association between clefting and cancer.

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Proper care can positively influence lives of children born with a cleft.

Educational Attainment of Children Born with Unilateral Cleft Lip and Palate in the United Kingdom

Objective:

This study evaluated association between functional outcomes in children born with unilateral cleft lip and palate (UCLP) and educational attainment.

Design:

Cleft Care UK (CCUK) was a United Kingdom (UK) wide cross-sectional study.

Setting:

UK Cleft Teams (data collected from all UK sites providing centralized cleft services).

Patients, Participants:

Five-year olds born with nonsyndromic UCLP (n = 268).

Main Outcome Measure(s):

National tests for educational attainment Key Stage 1 (KS1) undertaken by children at age 7 were linked to CCUK data to describe differences in educational attainment. Associations between functional outcomes and KS1 results were evaluated using regression analysis. We adjusted for birth month, gender, and an area-based measure of socioeconomic status.

Results:

Data were available for 205 children with UCLP. These children scored lower than national average (NA) scores across all subject areas, with a 0.62 lower score observed in the Average Point Score (APS; P = .01). There was association between being in a lower category for a cleft related outcomes and poorer KS1 results, with a trend for poorer attainment with higher numbers of poor functional outcomes. Those with 3 or more poor outcomes had a −2.26 (−3.55 to −0.97) lower APS compared to those with 0 to 1 poor outcomes.

Conclusions:

Children born with UCLP have poorer educational attainment at age 7 across all subject areas though differences were modest. Children with poor functional outcomes at age 5 had worse educational outcomes age 7. Improvements in functional outcomes could enhance educational outcomes.

Word Reading in Boys With Isolated Oral Clefts: Comparison to Unaffected Average and Dyslexic Readers Using the Dual-Route Model

OBJECTIVE

To examine word reading performance between boys with isolated cleft lip and/or palate (iCL/P), unaffected average reading (uAR), and unaffected impaired reading (uIR), using the dual-route model.

DESIGN

Case/control study.

SETTING

University children's hospital.

PARTICIPANTS

Males, between the ages of 8 to 11 years, with iCL/P (n = 26), uIR (n = 33), or uAR (n = 28).

METHODS

Single word reading and achievement were evaluated. Analyses of variance and analyses of covariance evaluated group differences in achievement. Medical records were reviewed for iCL/P participants for audiology and speech history. Spearman ρ correlations were calculated between hearing, speech, and reading achievement for the iCL/P group.

MAIN OUTCOME MEASURE(S)

Reading performance was evaluated using select subscales from the Woodcock Johnson Reading Mastery Test, 3rd Edition and the Test of Orthographic Competence.

RESULTS

Participants with iCL/P had higher than expected rates of reading impairment, differing across cleft type (0% iCL, 50% isolated cleft lip and palate [iCLP], 71.4% isolated cleft palate only [iCP]). On measures of word reading accuracy, iCL/P participants outscored uIR participants, with uAR participants scoring the highest. This pattern was specific to nonlexical reading tasks. Participants in the uAR and iCL/P groups outscored uIR participants on lexical tasks, with no significant differences between uAR and iCL/P. Evaluation of speech and hearing revealed no significant relationship to single word reading or achievement measures in the iCL/P group.

CONCLUSIONS

Boys with iCL/P are at a higher risk of reading impairments, particularly within the iCP subset. Regular screening should be encouraged, with skills from both lexical and nonlexical routes assessed.

Are predictors of reading impairment in isolated cleft similar to those in idiopathic dyslexia?

Children with isolated cleft of the lip and/or palate (iCL/P) are at increased risk for reading impairment. The purpose of this study was to evaluate the impact of early risk factors (hearing, speech, and early literacy) on reading performance compared to unaffected participants with average (uAR) and impaired (uIR) reading. Reading achievement and early literacy skills were evaluated across three groups (27 iCL/P, 32 uAR, and 33 uIR). All participants were males, ages 8-11 years old. Those with history of head trauma/injury or major medical/mental health conditions were excluded. Group differences in achievement and early literacy skills were evaluated with ANCOVAs. Participants with impaired reading achievement (at or below 25th Percentile) were identified. Medical record reviews for participates with iCL/P were conducted and audiology and speech ratings recorded. Correlations were calculated between achievement, early literacy, hearing, and speech. Participants with iCL/P had significantly elevated risk for reading impairment (37%); this risk differed by cleft type (0% iCL, 55% iCLP, and 60% iCP). Achievement for participants with iCP was similar to the uIR group. Early literacy risk resulted in lower achievement scores for both iCL/P and unaffected participants. History of inadequate hearing and speech did not significantly impact early literacy or achievement measures. There is a high risk of reading impairment for children with iCL/P-highest for those with iCLP and iCP. Early literacy predictors of reading outcome are similar for iCL/P and idiopathic dyslexia. Current screening and intervention methods are supported.

Health problems during childhood and school achievement: Exploring associations between hospitalization exposures, gender, timing, and compulsory school grades

Aims

To investigate while accounting for health at birth 1) associations between health problems during childhood, measured as hospitalizations, and school achievement in the final year of compulsory school, measured as overall grade points and eligibility for upper secondary education, 2) if and how gender moderates the association between health problems and school achievement, 3) if and how the timing of a health problem during childhood is associated with later school achievement.

Methods

Analyzes were performed on a population-based cohort (n = 115 196) born in 1990 in Sweden (51.3% boys, 48.7% girls) using data from several national registries. Multiple linear regression and logistic regression were used to analyze associations between study variables.

Results

Overall grade points and eligibility for continuation to upper secondary school were lower for individuals exposed to hospitalizations. Only the association between hospitalizations and overall grade points was moderated by gender and only for ages 13–16 years. Exposure close to actual grading had worst outcomes.

Conclusions

Health problems, measured through hospitalizations, was significantly associated with lower school achievements among Swedish children. Girls exposed to health problems requiring hospitalizations had relatively poorer school achievements as compared to boys. Health problems requiring hospitalization during junior high school had the greatest negative association with final achievement at compulsory school.

Associations Between Parenting Stress at School Entry and Later Psychosocial Adjustment: A Longitudinal Study of Children With Congenital Craniofacial Anomalies

OBJECTIVE

To examine the reciprocal relationships between parenting stress and psychosocial adjustment of children with congenital craniofacial anomalies (CFAs) at 2 time points: school entry and approximately 2.5 years later, after children had time to adjust to school.

DESIGN

Retrospective review of medical charts of children with CFAs.

SETTING

Department of reconstructive plastic surgery at an urban medical center.

PARTICIPANTS

Parents of 42 children aged 3.9 to 6.5 years at time 1 and 6.5 and 9.8 years at time 2.

MAIN OUTCOME MEASURES

Parenting Stress Index/Short Form and Child Behavior Checklist (CBCL), both completed by parents at time 1 and time 2.

RESULTS

Compared to norms, more parents scored in the clinical range on parenting stress both at time 1 and time 2. Parenting stress remained stable across the 2 time points. Although rates of psychosocial problems for boys were comparable to those of the CBCL normative sample, higher-than-expected rates of clinically significant internalizing and externalizing were found for girls at time 2. Parenting stress at time 1 was associated with child internalizing and externalizing problems at time 2. Whereas child externalizing problems at time 1 predicted parenting stress at time 2, child internalizing at time 1 showed trivial effects on time 2 parenting stress.

CONCLUSIONS

Early school years may be a period that is particularly stressful for parents of children with CFAs. There appears to be a transactional relationship between parenting stress and child psychosocial adjustment during the early school years.

Teachers’ Perspectives on the Impact of Cleft Lip and/or Palate During the School Years

Background:

Cleft lip and/or palate (CL/P) poses many challenges for those affected throughout the school years, with recent studies pointing to a trend in poor educational outcomes. Previous research has highlighted the important role that teachers play in supporting young people with chronic health conditions yet studies in the field of CL/P suggest that teachers may lack knowledge of the condition, and underestimate pupils’ academic ability. Qualitative investigation of the impact of CL/P from the teacher’s perspective may provide additional insight as well as potential suggestions for improving the school experience for affected pupils.

Methods:

Twenty UK preschool, primary, and secondary school teachers with experience of teaching pupils with CL/P completed an open-ended survey, eliciting qualitative data.

Results:

Qualitative content analysis was performed. Data were presented under 5 key headings: Knowledge of CL/P and its effects, perceived impact of CL/P on education, teachers’ training needs, delivery of training, and impact of CL/P on teachers. Teachers were able to identify a number of potential social, emotional, and treatment-related challenges within the school setting, yet did not believe that CL/P would have a long-term impact on pupils’ educational achievement. Participating teachers reported that cleft-specific training and access to relevant resources would be highly beneficial.

Conclusions:

Acting as a platform for future research, this exploratory study provides insight into the challenges faced by teachers and offers suggestions for how to improve teachers’ understanding of CL/P, and their confidence in dealing with cleft-related issues.

The Psychosocial Impact of Cleft in a Western Australian Cohort Across 3 Age Groups

BACKGROUND

Management of a cleft of the lip and/or palate (CL/P) involves a multidisciplinary team approach lasting from birth to potentially postskeletal maturity. This condition is complex, with both medical and psychosocial implications that may place individuals with a cleft at higher risk of developing psychosocial problems.

METHODOLOGY

A self-administered questionnaire was completed by a sample from the Western Australian cleft population comprising 3 age groups: child (n = 100), adolescent (n = 101), and adult (n = 158).

RESULTS

Public speaking, being photographed, special relationships, and participation in school were identified as the areas most impacted by having a cleft. Hearing and speech were reported to have a higher importance than facial and dental appearance. Participants rated support given to them by their parents as the most important, with high ratings for treatment providers. For teasing, the impact of cleft was significantly higher among participants with cleft lip and palate for both the adolescent and adult age groups. There was little significant difference by gender across the variables, which suggests that males are just as likely to require support as females.

CONCLUSION

The impact of a cleft across multiple psychosocial domains needs to be recognized and addressed as part of craniofacial team care across age groups.

Adult-Specific Life Outcomes of Cleft Lip and Palate in a Western Australian Cohort

BACKGROUND

People with a cleft of the lip and/or palate (CL/P) differ from their peers due to their facial appearance, hearing and speech difficulties, and the significant time spent attending appointments and recovering from surgical interventions. These differences may impact life outcomes including occupation, income, education, relationships, psychosocial health issues, and lifestyle choices.

METHODOLOGY

A self-administered questionnaire was posted to 338 former and current patients of the Cleft Lip and Palate Unit of Princess Margaret Hospital (PMH), Perth, Western Australia.

RESULTS

Completed questionnaires were returned by 158 former and current patients. In comparison to the Australian Bureau of Statistics, study participants attained equivalent highest education levels, full-time annual income levels, occupational categories, employment rates, and home ownership levels. They did not marry later and demonstrated positive health-related lifestyle behaviors. However independent living was significantly delayed, and the number of romantic relationships, marriages, and children was lower, with separation/divorce rates also being lower. A key finding was that 78% of participants self-reported that they experienced at least 1 psychosocial health issue and more than half experienced anxiety and/or depression.

CONCLUSION

When comparing the sociological outcomes for the study participants, the psychosocial outcomes were the areas of most concern. Further investigation is required to determine the causes for the high self-reported rates of anxiety and/or depression found in this study.

Early academic achievement in children with isolated clefts: a population-based study in England

OBJECTIVES

We used national data to study differences in academic achievement between 5-year-old children with an isolated oral cleft and the general population. We also assessed differences by cleft type.

METHODS

Children born in England with an oral cleft were identified in a national cleft registry. Their records were linked to databases of hospital admissions (to identify additional anomalies) and educational outcomes. Z-scores (signed number of SD actual score is above national average) were calculated to make outcome scores comparable across school years and across six assessed areas (personal development, communication and language, maths, knowledge of world, physical development andcreative development).

RESULTS

2802 children without additional anomalies, 5 years old between 2006 and 2012, were included. Academic achievement was significantly below national average for all six assessed areas with z-scores ranging from -0.24 (95% CI -0.32 to -0.16) for knowledge of world to -0.31 (-0.38 to -0.23) for personal development. Differences were small with only a cleft lip but considerably larger with clefts involving the palate. 29.4% of children were documented as having special education needs (national rate 9.7%), which varied according to cleft type from 13.2% with cleft lip to 47.6% with bilateral cleft lip and palate.

CONCLUSIONS

Compared with national average, 5-year-old children with an isolated oral cleft, especially those involving the palate, have significantly poorer academic achievement across all areas of learning. These outcomes reflect results of modern surgical techniques and multidisciplinary approach. Children with a cleft may benefit from extra academic support when starting school.

Common basis for orofacial clefting and cortical interneuronopathy

Orofacial clefts (OFCs) of the lip and/or palate are among the most common human birth defects. Current treatment strategies focus on functional and cosmetic repair but even when this care is available, individuals born with OFCs are at high risk for persistent neurobehavioral problems. In addition to learning disabilities and reduced academic achievement, recent evidence associates OFCs with elevated risk for a constellation of psychiatric outcomes including anxiety disorders, autism spectrum disorder, and schizophrenia. The relationship between these outcomes and OFCs is poorly understood and controversial. Recent neuroimaging studies in humans and mice demonstrate subtle morphological brain abnormalities that co-occur with OFCs but specific molecular and cellular mechanisms have not been investigated. Here, we provide the first evidence directly linking OFC pathogenesis to abnormal development of GABAergic cortical interneurons (cINs). Lineage tracing revealed that the structures that form the upper lip and palate develop in molecular synchrony and spatiotemporal proximity to cINs, suggesting these populations may have shared sensitivity to genetic and/or teratogenic insult. Examination of cIN development in a mouse model of nonsyndromic OFCs revealed significant disruptions in cIN proliferation and migration, culminating in misspecification of the somatostatin-expressing subgroup. These findings reveal a unified developmental basis for orofacial clefting and disrupted cIN development, and may explain the significant overlap in neurobehavioral and psychiatric outcomes associated with OFCs and cIN dysfunction. This emerging mechanistic understanding for increased prevalence of adverse neurobehavioral outcomes in OFC patients is the entry-point for developing evidence-based therapies to improve patient outcomes.

Young Person and Parent Perspectives on the Impact of Cleft Lip and/or Palate Within an Educational Setting

Background:

During the school years, a cleft of the lip and/or palate (CL/P) may pose a risk to educational achievement. To further understand this multifaceted association, and to offer suggestions as to how young people’s educational experiences might be improved, qualitative investigation is warranted.

Design:

Semi-structured telephone interviews were conducted with young people born with CL/P (n = 10; aged 10-16 years) and their parents (n = 10). The resulting data were subjected to inductive thematic analysis.

Results:

Negative social interactions, cleft-related treatment, the presence of an additional condition, and a lack of appropriate support from teachers was found to influence young people’s educational experience. Methods for promoting diversity, support from clinical teams, facilitation of positive school transitions, implementation of training for teachers, and a holistic approach to the measurement of “success” were suggested by participants as potential ways of improving this experience.

Conclusions:

The findings of this study point to a need for a range of school-focused interventions, as well as the inclusion of a number of potentially impactful variables within future quantitative research.

Arithmetical calculation and related neuropsychological skills in subjects with isolated oral clefts

OBJECTIVE

The current study examined whether the arithmetical calculation skills of children, adolescents, and young adults with isolated cleft of the lip and/or palate (iCL/P) differ significantly from unaffected control participants. Comparisons of potential neuropsychological predictors of arithmetical calculation were also conducted to determine whether these variables differ significantly for participants with iCL/P.

METHOD

Participants (N = 176; 93 iCL/P and 83 Control) ranged in age from 7 to 26 years old. A standardized battery of achievement and neuropsychological skills was administered. Between group differences on math achievement was assessed through a univariate analysis of covariance. Relationships between neuropsychological measures and math achievement were analyzed separately for participants with iCL/P and controls through hierarchical linear regressions.

RESULTS

Arithmetical calculation was significantly lower for the iCL/P group. Rapid naming, sustained attention, and visual-spatial organization were significant predictors for the iCL/P group; rapid naming was the lone variable that was significantly more predictive of arithmetical calculation for the iCL/P group than for control participants.

CONCLUSIONS

These results suggest that inefficient verbal label retrieval related to short-term memory (STM) deficits underlie the calculation difficulties of individuals with iCL/P. These findings have implications for approaches to remediation, as well as future research. (PsycINFO Database Record

Oral Clefts and Academic Performance in Adolescence: The Impact of Anesthesia-Related Neurotoxicity, Timing of Surgery, and Type of Oral Clefts

OBJECTIVE

Early life exposure to anesthesia and surgery is suspected to associate with cognitive impairment later in life. We compared academic achievement among adolescents with cleft lip only (CL), cleft palate only (CP), and cleft lip and cleft palate (CLP) with a noncleft control group to investigate whether outcome depends on timing and number of operations during childhood and/or type of oral cleft.

DESIGN

Nationwide register-based follow-up study.

SETTING

Danish birth cohort 1986 to 1990.

PARTICIPANTS

Five hundred fifty-eight children with isolated CL (n = 171), CLP (n = 222), or CP (n = 195), of which 509 children had been exposed to anesthesia and one or more cleft operation(s), and a 5% sample of the birth cohort (n = 14,677).

MAIN OUTCOME MEASURE(S)

Test score in the Danish standardized ninth-grade exam and proportion of nonattainment, defined as "results for ninth-grade exam unavailable." Data adjusted for sex, birth weight, parental age, and parental level of education.

RESULTS

Compared to controls, children with CL achieved higher scores (mean difference 0.12, 95% CI -0.05; 0.29) and children with CLP presented with lower scores (mean difference -0.06, 95% CI -0.21; 0.09), albeit both statistically insignificant. Children with CP achieved significantly lower scores, mean difference -0.20 (95% CI -0.38; -0.03). Odds ratios for nonattainment at final exam were: CL 0.79 (95% CI 0.46; 1.35), CLP 1.07 (95% CI 0.71; 1.61), CP 2.59 (95% CI 1.78; 3.76).

CONCLUSIONS

Oral cleft type rather than number and timing of anesthesia and operations associate to poorer academic performance. Although a potential neurotoxic effect due to anesthetic agents is not reflected in the data, it cannot be completely excluded.

Reexamining the Hypoglycemia Fear Survey for Parents of Young Children in a Sample of Children Using Insulin Pumps

BACKGROUND

We update the psychometric properties of the Hypoglycemia Fear Survey-Parents of Young Children (HFS-PYC), a 26-item measure of parents' hypoglycemia fear for young children using an insulin pump.

METHODS

We combined three similar datasets for the analyses. The data analyzed included parents' responses to the HFS-PYC and a demographic form. For a subset of children (n = 91), we also analyzed self-monitoring of blood glucose data. We used confirmatory factor analysis (CFA) to confirm the measure's original factor structure. Additional analyses examined reliability and validity of a revised HFS-PYC for parents of young children using pumps.

RESULTS

We analyzed data from 116 parents (93% mothers). Mean child age and HbA1c were 5.2 ± 1.3 years and 8.2% ± 1.1%, respectively. CFA identified a 22-item two-factor solution (χ² (208, n = 116) = 368.688, P < 0.001, root mean square error of approximation = 0.08, comparative fit index = 0.94, and Tucker-Lewis index = 0.93) with factors corresponding to the original subscales: worry and behavior. The revised subscales demonstrated at least adequate internal consistency (Cronbach's alpha >0.65). Correlations revealed significant negative associations between current HFS-PYC worry scores and children's mean daily blood glucose and percent of very high glucose levels per day, suggesting less fear among parents of young children with elevated glycemic levels. In addition, there was a positive association with the percent of glucose levels in target, suggesting greater hypoglycemia fear among parents of children who have better control.

CONCLUSIONS

Results provide preliminary evidence for the reliability and validity of a reduced 22-item HFS-PYC for parents of children using insulin pumps.

Socio-Economic Status and Reproduction among Adults Born with an Oral Cleft: A Population-Based Cohort Study in Norway

Background

It has been reported that people born with orofacial clefts do worse in life than their peers regarding a range of social markers, such as academic achievement and reproduction. We have compared otherwise healthy individuals with and without clefts, to investigate if these differences are due to the cleft or other background factors.

Materials and Methods

In a retrospective national cohort study, based on compulsory registers with data collected prospectively, we included everybody born in Norway between 1967 and 1992 (1490279 individuals, 2584 with clefts). This cohort was followed until the year 2010, when the youngest individuals were 18 years old. In order to ensure that the individuals were not affected by unknown syndromes or diseases, we excluded all individuals with any chronic medical condition, or who had other birth defects than clefts, hydroceles and dislocated hips. Individuals with oral clefts who were included in the study are said to have isolated clefts.

Results

Isolated cleft patients are similar to the general population regarding education, income and social class. Isolated cleft patients have lower fertility than the background population, but considering only married couples this difference in fertility disappeared.

Conclusions

An oral cleft did not appear to affect future socioeconomic status or chances of becoming a parent for children born in Norway. An exception was males with cleft lip and palate, but differences were small.

Passive Smoke Exposure as a Risk Factor for Oral Clefts-A Large International Population-Based Study

Maternal cigarette smoking is a well-established risk factor for oral clefts. Evidence is less clear for passive (secondhand) smoke exposure. We combined individual-level data from 4 population-based studies (the Norway Facial Clefts Study, 1996-2001; the Utah Child and Family Health Study, 1995-2004; the Norwegian Mother and Child Cohort Study, 1999-2009; and the National Birth Defects Prevention Study (United States), 1999-2007) to obtain 4,508 cleft cases and 9,626 controls. We categorized first-trimester passive and active smoke exposure. Multivariable logistic models adjusted for possible confounders (maternal alcohol consumption, use of folic acid supplements, age, body size, education, and employment, plus study fixed effects). Children whose mothers actively smoked had an increased risk of oral clefts (odds ratio (OR) = 1.27, 95% confidence interval (CI): 1.11, 1.46). Children of passively exposed nonsmoking mothers also had an increased risk (OR = 1.14, 95% CI: 1.02, 1.27). Cleft risk was further elevated among babies of smoking mothers who were exposed to passive smoke (OR = 1.51, 95% CI: 1.35, 1.70). Using a large pooled data set, we found a modest association between first-trimester passive smoking and oral clefts that was consistent across populations, diverse study designs, and cleft subtypes. While this association may reflect subtle confounding or bias, we cannot rule out the possibility that passive smoke exposure during pregnancy is teratogenic.